Gynecology 5th year, 6th lecture (Dr. Sindus)

Benign disease of the Benign disease of the uterusuterus

Benign disease of the uterus is an important problem for many Benign disease of the uterus is an important problem for many women and their gynaecologists. The commonest condition women and their gynaecologists. The commonest condition in this category is fibroids but adenomyosis and uterine in this category is fibroids but adenomyosis and uterine polyps are also of importance. Both fibroids and endometrial polyps are also of importance. Both fibroids and endometrial polyps are very common and although asymptomatic in polyps are very common and although asymptomatic in many women, they can cause considerable morbidity for many women, they can cause considerable morbidity for others.others.

Endometrial polypsEndometrial polyps

Endometrial polyps are discreet outgrowths of the Endometrial polyps are discreet outgrowths of the endometrium that contain a variable amount of endometrium that contain a variable amount of gland ,stroma and blood vessel. They are attached to the gland ,stroma and blood vessel. They are attached to the endometrium by a pedicle and they may be pedunculated or endometrium by a pedicle and they may be pedunculated or sessilesessile..

EpidemiologyEpidemiology

The presence of endometrial polyps is being increasingly The presence of endometrial polyps is being increasingly recognized since the widespread adoption of transvaginal recognized since the widespread adoption of transvaginal ultrasound and outpatients hysteroscopyultrasound and outpatients hysteroscopy . .

It is probable that they are present in 25% of women with It is probable that they are present in 25% of women with abnormal vaginal bleedingabnormal vaginal bleeding..

At least 10% of asymptomatic women are also likely to have At least 10% of asymptomatic women are also likely to have polypspolyps . .

They are particularly common in women taking preparations such They are particularly common in women taking preparations such as tamoxifenas tamoxifen . .

PresentationPresentation

Unscheduled vaginal bleeding or spotting is the commonestUnscheduled vaginal bleeding or spotting is the commonest

presentation for endometrial polypspresentation for endometrial polyps . .

They are frequently found in association with women They are frequently found in association with women experiencing abnormal bleeding while taking hormone experiencing abnormal bleeding while taking hormone replacement therapy (HRT) or tamoxifenreplacement therapy (HRT) or tamoxifen..

DiagnosisDiagnosis

11 – – Transvaginal ultrasoundTransvaginal ultrasound ,Intrauterine injection of saline ,Intrauterine injection of saline can markedly increase the diagnostic performance of can markedly increase the diagnostic performance of transvaginal ultrasoundtransvaginal ultrasound..

22 – – HysteroscopyHysteroscopy ,The best method for diagnosing polyps is ,The best method for diagnosing polyps is hysteroscopy; so it is a possibility that they might then be hysteroscopy; so it is a possibility that they might then be treated at the sametime. They can be distinguished from treated at the sametime. They can be distinguished from pedunculated fibroids since they have fewer vessels over the pedunculated fibroids since they have fewer vessels over the surfacesurface..

Malignant polyps are more likely to be irregular, vascular or Malignant polyps are more likely to be irregular, vascular or friable. Biopsy should be carried out to confirm the diagnosis friable. Biopsy should be carried out to confirm the diagnosis since appearance is not sufficientsince appearance is not sufficient..

TreatmentTreatment

In the symptomatic women, treatment will normally beIn the symptomatic women, treatment will normally be

performed under general anaesthesia. However, they canperformed under general anaesthesia. However, they can

also be treated in the outpatients setting either by removalalso be treated in the outpatients setting either by removal

under direct vision or by treatment with specially developedunder direct vision or by treatment with specially developed

diathermy instrumentationdiathermy instrumentation..

Uterine leiomyomata (fibroids)Uterine leiomyomata (fibroids) They are the most common neoplasm of the uterus, are They are the most common neoplasm of the uterus, are

clinically apparent in 20% of women of reproductive age and clinically apparent in 20% of women of reproductive age and maybe present in as many as 70% of uteri removed at maybe present in as many as 70% of uteri removed at hysterectomyhysterectomy . .

Their incidence is increased in women of Afro-Caribbean Their incidence is increased in women of Afro-Caribbean origin ,while decreased with prolonged use of the oral origin ,while decreased with prolonged use of the oral contraceptive pill as well as with increasing numbers of term contraceptive pill as well as with increasing numbers of term

pregnanciespregnancies . .

Although leiomyomas have the potential to grow to impressive Although leiomyomas have the potential to grow to impressive sizes, sizes, their malignant potential is minimal.their malignant potential is minimal. Sarcomatous Sarcomatous changes occur in less than 1 per 1000 uteri with fibroidschanges occur in less than 1 per 1000 uteri with fibroids..

Fibroids consist of varying proportions of smooth muscle andFibroids consist of varying proportions of smooth muscle and

fibroblasts. They may be single or multiple and can occur fibroblasts. They may be single or multiple and can occur anywhere in the uterusanywhere in the uterus..

Risk factors for developing leiomyomas include:Risk factors for developing leiomyomas include:

1 –1 – Increasing age during the reproductive years, Increasing age during the reproductive years,

2 – Ethnicity (African-American women have at least a 2- to 3-fold 2 – Ethnicity (African-American women have at least a 2- to 3-fold increased risk compared to Caucasian women), increased risk compared to Caucasian women),

3 – Nulliparity,3 – Nulliparity,

4 – Family history.4 – Family history.

5 – Higher body mass index is associated with a greater risk of 5 – Higher body mass index is associated with a greater risk of leiomyomata. leiomyomata.

Oral contraceptive pills and depot medroxyprogesterone Oral contraceptive pills and depot medroxyprogesterone acetate (DMPA) injections may be associated with reduced acetate (DMPA) injections may be associated with reduced risk.risk.

PathogenesisPathogenesis

Factors that initiate leiomyomata are not known, but ovarian sex Factors that initiate leiomyomata are not known, but ovarian sex steroids are important for their growth. Leiomyomas rarely steroids are important for their growth. Leiomyomas rarely develop before menarche and seldom develop or enlarge after develop before menarche and seldom develop or enlarge after menopause, unless stimulated by exogenous hormones. menopause, unless stimulated by exogenous hormones. Leiomyomas can also enlarge dramatically during Leiomyomas can also enlarge dramatically during pregnancy.pregnancy.

Leiomyomas have increased levels of estrogen and progesterone Leiomyomas have increased levels of estrogen and progesterone receptors compared to other smooth muscle cells. Estrogen receptors compared to other smooth muscle cells. Estrogen stimulates the proliferation of smooth muscle cell, whereas stimulates the proliferation of smooth muscle cell, whereas progesterone increases the production of proteins that interfere progesterone increases the production of proteins that interfere with programmed cell death (or apoptosis). with programmed cell death (or apoptosis).

Leiomyomas also have higher levels of growth factors that Leiomyomas also have higher levels of growth factors that stimulate the production of fibronectin and collagen, major stimulate the production of fibronectin and collagen, major components of the extracellular matrix that characterizes these components of the extracellular matrix that characterizes these lesions.lesions.

Characteristics Characteristics

Leiomyomas are usually spherical, well-circumscribed, white, firm Leiomyomas are usually spherical, well-circumscribed, white, firm lesions with a whorled appearance on cut section. Although the lesions with a whorled appearance on cut section. Although the leiomyoma appears discrete, it does not have a true cellular leiomyoma appears discrete, it does not have a true cellular capsule. Compressed smooth muscle cells on the tumor's periphery capsule. Compressed smooth muscle cells on the tumor's periphery provide the false impression of such a capsule. provide the false impression of such a capsule.

Few blood vessels and lymphatics traverse the pseudocapsule,Few blood vessels and lymphatics traverse the pseudocapsule, leading to degenerative changes as the tumors enlarge. leading to degenerative changes as the tumors enlarge. The most The most commonly observed degenerative change is that of commonly observed degenerative change is that of hyaline hyaline acellularityacellularity,, in which the fibrous and muscle tissues are replaced in which the fibrous and muscle tissues are replaced with hyaline tissue. If the hyaline substance breaks down from a with hyaline tissue. If the hyaline substance breaks down from a further reduction in blood supply, further reduction in blood supply, cystic degeneration cystic degeneration may may occur. occur.

CalcificationCalcification may occur in degenerated fibroids, may occur in degenerated fibroids, particularly after particularly after the menopause. the menopause. FattyFatty degenerationdegeneration may also occur may also occur but is rare. but is rare.

During pregnancy, 5% to 10% of women with fibroids undergo During pregnancy, 5% to 10% of women with fibroids undergo a painful a painful red or carneous degenerationred or carneous degeneration caused by hemorrhage caused by hemorrhage into the tumor. into the tumor.

Leiomyomas arise within the myometrium Leiomyomas arise within the myometrium (intramural),(intramural), but but some migrate toward the serosal surface some migrate toward the serosal surface (subserosal)(subserosal) or or toward the endometrium toward the endometrium (submucosal)(submucosal) . .

Individual tumors may migrate further by developing large Individual tumors may migrate further by developing large pedicles. The submucosal leiomyomas can extend through the pedicles. The submucosal leiomyomas can extend through the endometrial canal and about from the cervical os. An aborting endometrial canal and about from the cervical os. An aborting leiomyoma causes significant bleeding and cramping pain. A leiomyoma causes significant bleeding and cramping pain. A subserosal leiomyoma on a long pedicle can present as a mass subserosal leiomyoma on a long pedicle can present as a mass that feels separate from the uterusthat feels separate from the uterus . .

Rarely, pedunculated subserosal myomata attach to the blood Rarely, pedunculated subserosal myomata attach to the blood supply of the omentum or bowel mesentery and lose their supply of the omentum or bowel mesentery and lose their uterine connection to become uterine connection to become parasitic leiomyomasparasitic leiomyomas..

Leiomyomas can also arise in the cervix, between the leaves of Leiomyomas can also arise in the cervix, between the leaves of the broad ligament (intraligamentous), and in the various the broad ligament (intraligamentous), and in the various supporting ligaments (round or uterosacral) of the uterussupporting ligaments (round or uterosacral) of the uterus..

Symptoms associated with uterine fibroids:Symptoms associated with uterine fibroids:

1 –1 – The majority of uterine leiomyomas cause no The majority of uterine leiomyomas cause no symptoms(50%).symptoms(50%).

22 – – Uterine fibroids commonly present with Uterine fibroids commonly present with menstrual problemsmenstrual problems

particularly heavy menstrual bleedingparticularly heavy menstrual bleeding..

Menorrhagia may be associated with intramural or Menorrhagia may be associated with intramural or submucosal tumor. Metrorrhagia has been associated with submucosal tumor. Metrorrhagia has been associated with submucous myomas ulcerating through the endometrial submucous myomas ulcerating through the endometrial lining.lining. Excessive bleeding may result in anemia, weakness, Excessive bleeding may result in anemia, weakness, dyspnea, and even congestive heart failure. dyspnea, and even congestive heart failure.

Recently it has been shown that Menorrhagia is not just confined to Recently it has been shown that Menorrhagia is not just confined to those who have submucous fibroids but can also be associated those who have submucous fibroids but can also be associated with subserosal lesionswith subserosal lesions..

33 – – DysmenorrhoeaDysmenorrhoea can be an additional problem leading to misery can be an additional problem leading to misery for the women affectedfor the women affected..

There is an increased incidence of secondary dysmenorrhea in There is an increased incidence of secondary dysmenorrhea in women with uterine myomas, generally caused by the increased women with uterine myomas, generally caused by the increased blood lossblood loss..

44 – – Symptoms related purely to the size of the fibroid. This may be a Symptoms related purely to the size of the fibroid. This may be a feeling of dragging or pressure in the pelvis or simply that of feeling of dragging or pressure in the pelvis or simply that of abdominal swellinabdominal swellingg..

She may complain of pelvic pressure, congestion, bloating, She may complain of pelvic pressure, congestion, bloating, a feeling of heaviness in the lower abdomen, or lower back a feeling of heaviness in the lower abdomen, or lower back pain.pain. She may note frequency of urination. Urinary retention and She may note frequency of urination. Urinary retention and hydronephrosis are rare but result from the fact that the bladder hydronephrosis are rare but result from the fact that the bladder and large leiomyomas compete for space within the pelvisand large leiomyomas compete for space within the pelvis..

In addition, pressure pains may occur in the lower abdomen and In addition, pressure pains may occur in the lower abdomen and pelvis if a myomatous uterus becomes incarcerated within the pelvis if a myomatous uterus becomes incarcerated within the pelvispelvis . .

55 – – DyspareuniaDyspareunia is also common with incarceration is also common with incarceration . .

66 – – Subfertility ,Difficulty in conceiving ,Pregnancy loss ,Intrapartum Subfertility ,Difficulty in conceiving ,Pregnancy loss ,Intrapartum

bleeding (particularly Caesarian sectionbleeding (particularly Caesarian section), ), are other problems that are other problems that may may be caused by fibriodmay may be caused by fibriod..

77 – – Bowel problemBowel problem..

SignsSigns::

Very large fibroids can be palpated abdominally. Those smaller Very large fibroids can be palpated abdominally. Those smaller than a 12- to 14-week gestational size are usually confined to than a 12- to 14-week gestational size are usually confined to the pelvis. The bladder should be emptied before examination to the pelvis. The bladder should be emptied before examination to avoid the confusion of urinary retention. Although submucous avoid the confusion of urinary retention. Although submucous fibroids may not be palpable, fibroids may not be palpable, on bimanual pelvic on bimanual pelvic examination a firm, irregularly enlarged uterus with examination a firm, irregularly enlarged uterus with smoothly rounded or bosselated protrusions may be felt smoothly rounded or bosselated protrusions may be felt if the tumors are subserosal or intramural.if the tumors are subserosal or intramural. The tumors are The tumors are usually nontender. Their consistency may vary from rock hard, usually nontender. Their consistency may vary from rock hard, as in the case of a calcified postmenopausal leiomyoma, to soft as in the case of a calcified postmenopausal leiomyoma, to soft or even cystic, as in the case of cystic degeneration of the or even cystic, as in the case of cystic degeneration of the tumortumor . .

In general, the myomatous masses are in the midline, but In general, the myomatous masses are in the midline, but sometimes a large portion of the tumor lies in the lateral sometimes a large portion of the tumor lies in the lateral aspect of the pelvis and may be indistinguishable from an aspect of the pelvis and may be indistinguishable from an adnexal mass. adnexal mass. If the mass moves with the cervix, it is If the mass moves with the cervix, it is suggestive of a leiomyomasuggestive of a leiomyoma..

DiagnosisDiagnosis::

11 – – Ultrasonography is very useful as first line investigationUltrasonography is very useful as first line investigation..

22 – – MRI scan can give excellent visualization of the uterus and MRI scan can give excellent visualization of the uterus and ovaries. In addition, enhancement with gadolinium gives an ovaries. In addition, enhancement with gadolinium gives an indication of the vascularity of the uterusindication of the vascularity of the uterus..

Biopsy of the fibroid is not commonly undertakenBiopsy of the fibroid is not commonly undertaken..

Pregnancy Complications Due to LeiomyomPregnancy Complications Due to Leiomyomaa

11--AbortionAbortion

22--Premature laborPremature labor

33--Disturbances in laborDisturbances in labor

44--Postpartum hemorrhagePostpartum hemorrhage

((( ( questionablequestionable

55--Ectopic pregnancyEctopic pregnancy

66--Premature rupture of Premature rupture of membranemembrane

77--Dystocia secondary low Dystocia secondary low segment myomasegment myoma

88--Increase operative Increase operative deliveriesdeliveries

99--Inversion of uterusInversion of uterus

Differential DiagnosisDifferential Diagnosis::

The most common differential diagnoses areThe most common differential diagnoses are

11 – – An ovarian neoplasmAn ovarian neoplasm , ,

22 – – A tubo-ovarian inflammatory massA tubo-ovarian inflammatory mass , ,

33 – – A pelvic kidneyA pelvic kidney , ,

44 – – A diverticular or inflammatory bowel mass,or cancer of the A diverticular or inflammatory bowel mass,or cancer of the coloncolon..

Treatment of uterine fibroidsTreatment of uterine fibroids::

In general, if a small In general, if a small asymptomaticasymptomatic fibroid is detected, a fibroid is detected, a repeat ultrasonic examination within 6 months is prudent to repeat ultrasonic examination within 6 months is prudent to rule out a rapidly growing uterine sarcomarule out a rapidly growing uterine sarcoma . .

If menorrhagia is the chief complaint, it is imperative that If menorrhagia is the chief complaint, it is imperative that an endometrial aspiration or a fractional dilatation and an endometrial aspiration or a fractional dilatation and curettage (D&C) be performed to rule out related pathologycurettage (D&C) be performed to rule out related pathology

Medical ManagementMedical Management: :

MenorrhagiaMenorrhagia caused by fibroids may be managed caused by fibroids may be managed hormonally in many cases. hormonally in many cases. Progestin-only therapiesProgestin-only therapies (oral or injected medroxyprogesterone acetate, progestin-(oral or injected medroxyprogesterone acetate, progestin-only oral contraceptive pills, or levonorgestrel-releasing only oral contraceptive pills, or levonorgestrel-releasing intrauterine devices) intrauterine devices) or combination hormonal or combination hormonal contraceptive methodscontraceptive methods (oral contraceptive pills, vaginal (oral contraceptive pills, vaginal rings, or patches) rings, or patches) are usually a first therapeutic optionare usually a first therapeutic option..

The goal may be to reduce monthly menstrual blood loss with The goal may be to reduce monthly menstrual blood loss with cyclic hormonal methods or to eliminate menses with cyclic hormonal methods or to eliminate menses with extended or continuous use of these methodsextended or continuous use of these methods..

GnRH agonists have demonstrated considerable GnRH agonists have demonstrated considerable efficacyefficacy in blocking ovarian steroidogenesis, which halts in blocking ovarian steroidogenesis, which halts endometrial proliferation. Simultaneously, GnRH agonists endometrial proliferation. Simultaneously, GnRH agonists reduce the volume of the myometrium and the reduce the volume of the myometrium and the leiomyomas. This allows for correction of anemia and leiomyomas. This allows for correction of anemia and reduces intraoperative blood loss. reduces intraoperative blood loss. The effects of GnRH-The effects of GnRH-agonist therapy disappear soon after the drug is agonist therapy disappear soon after the drug is stopped.stopped. However, because of the intense vasomotor However, because of the intense vasomotor symptoms and the deleterious effect the GnRH-agonists symptoms and the deleterious effect the GnRH-agonists may have on bone mineral density, only short courses of may have on bone mineral density, only short courses of these agonists can be administered, usually in preparation these agonists can be administered, usually in preparation for myomectomy or hysterectomyfor myomectomy or hysterectomy . .

Intermittent GnRH- agonist administration has been shown Intermittent GnRH- agonist administration has been shown to reduce side effects while achieving therapeutic goals to reduce side effects while achieving therapeutic goals longer term. longer term. Combining GnRH agonists with hormonal Combining GnRH agonists with hormonal agents, such as low-dose progesterone or agents, such as low-dose progesterone or estrogen/progestin combinations, may minimize estrogen/progestin combinations, may minimize some adverse effects of hypoestrogenism (such as some adverse effects of hypoestrogenism (such as osteoporosis), but long-term data are not availableosteoporosis), but long-term data are not available..

Clinical trials using the selective antiprogesterone Clinical trials using the selective antiprogesterone receptor antagonist, mifepristone (RU 486), to receptor antagonist, mifepristone (RU 486), to reduce the size of uterine myomas have shown a reduce the size of uterine myomas have shown a reduction of 50% over a 3-month period.reduction of 50% over a 3-month period. Doses of 5, Doses of 5, 25, or 50 mg/day for up to 6 months have been used to 25, or 50 mg/day for up to 6 months have been used to ablate endometriosis and to reduce the size of uterine ablate endometriosis and to reduce the size of uterine myomas without producing the changes in bone density myomas without producing the changes in bone density noted with GnRH agonists and without untoward noted with GnRH agonists and without untoward glucocorticoid effectsglucocorticoid effects..

Surgical ManagementSurgical Management : :

Medical therapy is of limited value in treating the other Medical therapy is of limited value in treating the other problems posed by leiomyoma. Surgical interventions are problems posed by leiomyoma. Surgical interventions are important to treat these problems as well as to treat important to treat these problems as well as to treat leiomyoma that are not responsive to medical leiomyoma that are not responsive to medical managementmanagement..

11 – – Myomectomy is the preferred surgical procedure for Myomectomy is the preferred surgical procedure for women with a limited number of tumors who desire women with a limited number of tumors who desire uterine preservationuterine preservation . .

Myomectomy occasionally can be performed hysteroscopically Myomectomy occasionally can be performed hysteroscopically for submucous masses or transabdominally (either for submucous masses or transabdominally (either laparoscopically or with laparotomy) for other leiomyomaslaparoscopically or with laparotomy) for other leiomyomas . .

Pretreatment for 3 months with GnRH agonists and the use of Pretreatment for 3 months with GnRH agonists and the use of vasoconstrictive agents intraoperatively may improve vasoconstrictive agents intraoperatively may improve surgical outcomes whatever surgical approach is usedsurgical outcomes whatever surgical approach is used..

Myomectomy may not be successful in avoiding Myomectomy may not be successful in avoiding hysterectomy.hysterectomy. Not all the tumors may be removed, and Not all the tumors may be removed, and new leiomyomata may grow in the future. About 25% of new leiomyomata may grow in the future. About 25% of women will require a subsequent operation. women will require a subsequent operation. If the If the endometrial cavity is entered during myomectomy, endometrial cavity is entered during myomectomy, future deliveries must be by cesareanfuture deliveries must be by cesarean..

Hysteroscopy and fibriodHysteroscopy and fibriod

22 – – Hysterectomy provides definitive therapy.Hysterectomy provides definitive therapy. If the If the uterus is large (>12 to 14 cm), laparotomy is generally the uterus is large (>12 to 14 cm), laparotomy is generally the preferred approachpreferred approach . .

Vaginal hysterectomy is generally preferred if the Vaginal hysterectomy is generally preferred if the uterus is not bulkyuterus is not bulky and the vagina is not constricted. and the vagina is not constricted. Laparoscopically assisted vaginal hysterectomy permits Laparoscopically assisted vaginal hysterectomy permits excellent visualization of the adnexae and controlled excellent visualization of the adnexae and controlled dissection from above without a large abdominal incisiondissection from above without a large abdominal incision . .

Rapid growth of a uterus caused by leiomyoma (doubling in Rapid growth of a uterus caused by leiomyoma (doubling in size in <6 months) may be the result of leiomyosarcoma, size in <6 months) may be the result of leiomyosarcoma, and hysterectomy is generally recommendedand hysterectomy is generally recommended..

Other therapies are emerging, especially for women who Other therapies are emerging, especially for women who desire uterine preservationdesire uterine preservation . .

33 – – Embolization of the uterine arteries supplying the Embolization of the uterine arteries supplying the leiomyomas has been found to be effective,leiomyomas has been found to be effective, at least in at least in the short term, for controlling leiomyoma-induced bleeding the short term, for controlling leiomyoma-induced bleeding and to shrink the myomasand to shrink the myomas..

44 – – Endometrial ablation with hysteroscopic resection, Endometrial ablation with hysteroscopic resection, laser ablation, or roller ball may be technically laser ablation, or roller ball may be technically difficult if the leiomyomata distort the cavity,difficult if the leiomyomata distort the cavity, but the but the newer thermal balloon methods may be successful. This newer thermal balloon methods may be successful. This approach may be appropriate for women who are poor approach may be appropriate for women who are poor candidates for more extensive surgerycandidates for more extensive surgery

55 – – Laser ablation of fibroids can be carried out at surgery Laser ablation of fibroids can be carried out at surgery either using a hysteroscope or a laparoscope depending on either using a hysteroscope or a laparoscope depending on the position of the fibroids. Laser can also be used withthe position of the fibroids. Laser can also be used with

MRI or ultrasound guidanceMRI or ultrasound guidance..

Alternatively MRI guidance can be used to focus ultrasound Alternatively MRI guidance can be used to focus ultrasound and fibroid necrosis occurs without significant adverse and fibroid necrosis occurs without significant adverse outcomesoutcomes..

Leiomyomata UterusLeiomyomata Uterus